Runaway History and Past 30-Day Opioid Misuse in Justice-Involved Adolescents

Abstract

This study used a sample from the Florida Department of Juvenile Justice (n= 79,960) to analyze the association between runaway history and past 30-day opioid misuse (OM) among justice involved adolescents. Past 30-day OM was confirmed using a urine analysis. Adolescents who were runaways in their lifetime were twice as likely to misuse opioids, and those who were runaways at the time of arrest were three times as likely to be opioid misusers compared to adolescents who never ran away or been kicked out of a home. These findings emphasize a need for resources that focus on developing strong attachment bonds.

INTRODUCTION

Misuse of opioids has devastated many American families, resulting in opioid use disorders, drug overdoses, and related fatalities. Nearly 12 million people in the United States misused opioids in 2017, including roughly 891,000 adolescents between 12 and 17 (SAMHSA, 2017). During that same period, nearly 175 people in the U.S. died each day due to opioid misuse (Christie et al., 2017). Adolescence is a critical stage of development (Sawyer, Azzopardi, Wickremarathne, & Patton, 2018), and opioid misuse during this stage is associated with severe and lasting consequences. Displacement, such as running away or being thrown away from their homes, is a chief public health concern that may increase risk for opioid misuse among minors. The juvenile justice system has become a de facto behavioral healthcare system (Kumm, Mathur, Cassavaugh, & Butts, 2020), especially for children and adolescents deemed runaways (Morewitz, 2016). Not surprisingly, justice-involved adolescents (JIA) have a higher risk and suffer harsher consequences for substance misuse and displacement from home (Abram et al., 2015; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). To develop precise intervention to reduce opioid misuse among these critically vulnerable youth, deeper insights into the relationship between runaway episodes and opioid misuse among JIA are needed. This Florida study seeks to add insights.

Opioid Use in Adolescents

Data indicates that among adolescents, opioids have become the second most widely misused drug after marijuana (Lipari, Van Horn, Hughes, & Williams, 2017; NIDA, 2020b; Office of Adolescent Health, 2019; Sung, Richter, Vaughan, Johnson, & Thom, 2005). Opioid misuse among adolescents can detrimentally affect every area of life such as unsatisfactory grades, poor performance in sports, unhealthy relationships with friends and family, and impaired judgment (NIDA, 2020a). Data also indicates that both prescription and illicit opioid misuse are declining among adolescents in the general population (Johnston et al., 2018; NIDA, 2017). However, prevalence remains dangerously high. Among youth between 15 and 19 who overdosed on drugs, the highest death rates were found among those who used opioids (Curtin, Tejada-Vera, & Warner, 2017). Heroin was the most common opioid used among youth who died of an overdose and most of these overdoses were not intentional (Curtin et al., 2017).

Runaways

Approximately five to eight percent of adolescents run away from home annually (Gambon & Gewirtz O’Brien, 2020; SAMHSA, 2004; Sanchez, Waller, & Greene, 2006; Sedlak, Finkelhor, & Brick, 2017; K. A. Tyler & Bersani, 2008). Approximately 550,000 youth and young adults were homeless or unaccompanied by a guardian, and more than half of these youth were under 18 (Homelessness, 2018). A runaway episode typically refers to when a minor leaves home without permission and stays away overnight for at least one night (for children younger than 15) or at least two nights (for children 15 or older). A thrownaway episode typically refers to when a minor is asked or told to leave home by an adult caregiver or is prevented from returning home by an adult caregiver for at least one night when no alternative shelter is arranged (Sedlak et al., 2017). Distinguishing between these two terms is challenging because they often co-occur or because classifications vary based on the perspectives of the persons involved (Gambon & Gewirtz O’Brien, 2020). Therefore, runaway and thrownaway episodes are often combined in research. Consistent with previous research, this article uses “run-away” to refer to both terms.

The elements of social bonding can help explain the association of runaway status to OM among JIA. Hirschi’s social control theory (2002) proposes that deviant behaviors can be understood through social bonding, including attachment to parents and peers, commitment to societal norms and institutions, involvement in conventional activities, and beliefs in conventional values. The correlation between elements of social bonding explains that the closer an individual is connected to society in a conventional way and is attached to conventional people, the greater the likelihood of involvement in conventional activities, thus accepting conventional ideals of conduct (Hirschi, 2002). Hirschi (2002) states that positive attachment to conventional individuals is the main safeguard for deviance among youth, and hence that the weaker the bond, the greater the likelihood for delinquency. With a focus on the attachment component of the social control theory, running away from home represents a lack of prosocial bonding or strain that is needed to deter adolescents from OM and helps explain the role that social bonding plays in substance use.

Few studies have assessed the association of social bonding to substance abuse using theoretical linkage (Erickson, Crosnoe, & Dornbusch, 2000; Ford & Rigg, 2015). Ford and Rigg (2015) examined measures associated with social control theory to establish a relationship of prescription OM among adolescents. Their study shows a significant correlation between adolescents having strong bonds with parents and school associated with a decreased likelihood to misuse opioids. The correlation between Hirschi’s concept of attachment in social control theory and deviant behaviors such as substance use and running away suggests a relationship between runaway status and OM.

Adolescents who run away from home are at risk of substance use and substance use disorders (S. J. Thompson, Barczyk, Gomez, Dreyer, & Popham, 2010), including prescription opioid misuse and heroin use. The rate of substance use among homeless and runaway youth exceeds substance use rates among youth who remain in the home (Baer, Ginzler, & Peterson, 2003; Gomez, Thompson, & Barczyk, 2010; Greene, Ennett, & Ringwalt, 1997; Merscham, Van Leeuwen, & McGuire, 2009; Milburn, Rotheram-Borus, Rice, Mallet, & Rosenthal, 2006; S. Thompson, Jun, Bender, Ferguson, & Pollio, 2010; Wenzel, Tucker, Golinelli, Green, & Zhou, 2010). Homeless youth have high rates of prescription drug misuse (Rhoades, Winetrobe, & Rice, 2014). Rhoades and colleagues (2014) found that among a sample of 451 homeless youth, more than 21% reported prescription drug misuse; approximately 25% reported use of opioids within the past year, representing the largest percentage of prescription drug misuse. Furthermore, (Al-Tayyib, Rice, Rhoades, & Riggs, 2014) determined that homeless youth who misused prescription drugs had more than a seven-fold increase in the risk of being an injection drug user. This association is further exacerbated by the concurrent misuse of prescription drugs with heroin, cocaine, or methamphetamine, which increased the risk of injection drug use approximately 15 times (Al-Tayyib, Rice, Rhoades, & Riggs, 2014).

In addition to substance use, homelessness is often clustered with other risk factors, including unprotected sex (Rhoades et al., 2014), suicidal ideation (Rhoades et al., 2014), mental health problems (Tucker, Edelen, Ellickson, & Klein, 2011), sexual abuse (Coates & McKenzie-Mohr, 2010; Greene, Ennett, & Ringwalt, 1999; Unger et al., 1998), or physical abuse (Coates & McKenzie-Mohr, 2010). These additional risks can exacerbate the effects of substance use among adolescents who run away from home. Life on the streets has the potential to erode the emotional and physical welfare of adolescent runaways as risky methods of survival are employed (Miles & Okamoto, 2008). Runaway youth are often criminalized. In 2019, approximately 696,620 youth were involved in the juvenile justice system (OJJDP, 2020a). Thousands of adolescents enter the juvenile justice system due to running away from home because running away from home is a status offense in many states (CJJ, 2020). Approximately 10% of status offense cases brought before the courts involve adolescents who run away from home (OJJDP, 2020b).

JIA may represent a population that is particularly at risk of opioid misuse and particularly subject to harsher consequences. Runaway experiences are associated with justice-involvement and substance abuse. Homelessness is associated with several factors that are linked to adolescent substance abuse, including exposure to psychological trauma and deviant peers. In a study of homeless youth, Johnson, Whitbeck, and Hoyt (2005) found that the strongest factor associated with meeting the diagnostic criteria for substance use disorders was an association with deviant peers. The data indicated that for every one-unit increase in affiliation with deviant peers, youth were six times more likely to meet the criteria for substance use disorder. Many homeless youth are often exposed to traumatic experiences before and after they leave home (Tucker et al., 2011), and those with a history of trauma may abuse substances as a coping mechanism (Kimberly A. Tyler, Gervais, & Davidson, 2013).

This study assesses the association between runaway status and opioid use among youth involved in the justice system.

METHODS

Population

Youth enter the Florida Department of Juvenile Justice (FLDJJ) system through receiving an official sanction or an arrest. During the intake process, trained FLDJJ data collectors administer the Positive Achievement Change Tool (PACT) assessment via indepth interviews and code the data using the FLDJJ coding software. FLDJJ provided data on all youth in the FLDJJ system who reached the age of 18 from 2007 to 2016. All JIA in the FLDJJ dataset received one or more official referrals for delinquency (equivalent to an adult arrest) and completed the PACT assessment. The FLDJJ data consisted of a cohort of 79,960 juveniles. Nearly 38.3% were non-Latinx White (n=30,591), 45.6% of subjects were non-Latinx Black or African American (n=36,443), 15.7% were Latinx (n=12,536), and 0.5% were another race (n=390). Roughly 21.9% of the sample were female (n= 17,497) and the mean age in 2007 was 14.

Measures

Opioid misuse

The construct current opioid misuse, abbreviated as OM, refers to using prescription opioids non-medically and/or illicit opioids in the past 30 days. Use was determined using a urine analysis. OM was defined by a binary measure that quantifies whether the youth reported nonmedical or illicit opioids. The response items were (0) “none” or (1) “opioids, heroin, or other opioids”. The data sources include self-reported data collected during the intake interview and official documents (such as arrests for OM or diagnosis of opioid use disorder).

Runaway

Current runaway refers to (1) JIA who were away from home or chose not to come home when expected to, and had stayed away multiple nights at the time of arrest/assessment; and/or (2) JIA who were away from home at the time of the arrest/assessment and were prevented from returning home by a parent or other household adult, no adequate alternative care was arranged for the child by a household adult, and the child was out of the household overnight. As suggested in prior research, runaway and thrownaway experiences were combined (Gambon & Gewirtz O’Brien, 2020; Hammer, Finkelhor, & Sed-lack, 2002). JIA were asked about their history of running away from home or being kicked out of the home. The independent variable, runaway status, was categorized into three categories, including: (1) JIA who have never run away or been kicked out of a home; (2) JIA who have run away or been kicked out of a home in the past; and (3) JIA who were current runaways or had been kicked out of the home at the time of arrest.

Covariates

Sociodemographic factors were self-reported and included race (White, Black, Latinx, other), gender (male, female), age, and household income (under $15,000, $15,000 to $34,999, $35,000 to $49,999, or $50,000 and over). History of mental health problems was assessed by FLDJJ and retrieved from a credentialed authority or through verification of self-reported mental health problems. A dichotomous variable of the child’s history of mental health diagnoses at intake was used to measure problematic mental health history.

Data Analysis

All analyses were conducted using STATA 13 SE. Chi-square tests were used to summarize descriptive statistics of runaway status, sociodemographic factors, and mental health status based on current opioid use status. Multivariate logistic regression was used to investigate the association between runaway status and current opioid use among JIA, adjusting for race, gender, age, household income, and mental health history. A variance inflation factor of four was used to assess the severity of multicollinearity. The Box-Tidwell test was conducted to assess the linearity of log-odds.

RESULTS

Table 1 displays the characteristics of JIA in the sample by past 30-day OM. Nearly 3% of JIA used opioids, 30% had lifetime runaway experiences, and nearly 3% were runaways at the time of arrest/assessment. JIA who misused opioids in the past 30 days tended to have been a runaway in their lifetime, male, White, and in the combined annual household income range of $15,000 to $34,999. They were also more likely to have never suffered from depression and/or anxiety but committed school misconduct that resulted in calls to the police.

TABLE 1.

Characteristics of Justice-Involved Adolescents by Past 30-Day Opioid Misuse.

	Total (n=79,960)		No Opioid Misuse (n=77,823)		Opioid Misuse (n=2,131)
	n	%	n	%	n	%
Runaway/Throwaway History
Never	53,760	67.2	52,978	68.1	782	36.6
Lifetime	24,124	30.2	22,902	29.4	1,222	57.2
Current	2,076	2.6	1,943	2.5	133	6.2
Gender
Male	62,463	78.1	61,006	78.4	1,457	68.2
Female	17,497	21.9	16,817	21.6	680	31.8
Race
White	30,591	38.3	28,868	37.1	1,723	80.6
Black	36,443	45.6	36,266	46.6	177	8.3
Latinx	12,536	15.7	12,318	15.8	218	10.2
Other	390	0.5	371	0.5	19	0.9
Mean Age (Standard Deviation)	14.13 (2.22)		14.14(2.22)		13.90 (2.10)
Household Income
Under $15,000	20,715	25.9	20,248	26	467	21.9
From $15,000 to $34,999	41,883	52.4	40,864	52.5	1,019	47.7
From $35,000 to $49,999	11,842	14.8	11,445	14.7	397	18.6
$50,000 & over	5,520	6.9	5,266	6.8	254	11.9
History of Depression/Anxiety
None	50,633	63.3	49,812	64	821	38.4
Occasional	21,986	27.5	21,176	27.2	810	37.9
Consistent	6,247	7.8	5,837	7.5	410	19.2
Impairment	1,094	1.4	998	1.3	96	4.5
School Conduct
Positive Recognition	3,283	4.1	3,254	4.2	29	1.4
No Problems	25,756	32.2	25,303	32.5	453	21.2
Problems Reported by Teachers	13,821	17.3	13,481	17.3	340	15.9
Problem Calls to Parents	15,004	18.8	14,521	18.7	483	22.6
Calls to Police	7,714	9.6	7,490	9.6	224	10.5
Graduated	2,706	3.4	2,605	3.3	101	4.7
Dropped Out	11,676	14.6	11,169	14.4	507	23.7

Table 2 displays the results of the multivariate logistic regression model estimating the adjusted odds ratios of past 30-day OM by runaway history. After adjusting for gender, race, age, household income, depression history, and school misconduct, JIA who experienced lifetime runaway were 2.6 times more likely to report past 30-day OM than JIA who never had a runaway experience. JIA who were current runaways at the time of arrest were 3.3 times more likely to have misused opioids in the past 30 days compared to JIA who were never runaways.

TABLE 2.

Logistic Regression Estimating Past 30-Day Opioid Misuse.

	AOR	CI
Runaway/Throwaway History (Ref=Never)	-	-
Lifetime	2.64***	[2.40,2.91]
Current	3 36***	[2.75,4.09]
Gender (Ref=Male)	-	-
Female	1.15**	[1.04,1.26]
Race (Ref=White)	-	-
Black	0.10***	[0.09,0.12]
Latina/O	0.36***	[0.31,0.42]
Other	0.97	[0.60,1.55]
Age In 2007	0.94***	[0.93,0.96]
Income (Ref=Under $15,000)	-	-
From $15,000 to $34,999	1.06	[0.95,1.19]
From $35,000 to $49,999	1.16*	[1.01,1.34]
$50,000 & Over	1 38***	[1.17,1.62]
History ofDepression-Anxiety (Ref=None)	-	-
Occasional	1.52***	[1.37,1.69]
Consistent	2.12***	[1.86,2.41]
Impairment	2.49***	[1.97,3.13]
School Conduct (Ref=Recognition)	-	-
No Problems in School Conduct	1.69**	[1.15,2.47]
Problems Reported by Teachers	2.21***	[1.50,3.25]
Problem Calls to Parents	2.70***	[1.85,3.96]
Calls to Police	2.61***	[1.76,3.87]
Graduated	3.03 ***	[1.99,4.61]
Dropped Out	3.27 ***	[2.23,4.78]
Constant	0.02***	[0.01,0.04]
Observations	79,960

AOR= Adjusted odds ratios. 95% confidence intervals (CI) in brackets.

^*p < 0.05

^**p < 0.01

^***p < 0.001

All of the control variables in Table 1 were significantly related to the likelihood of OM: Females were 15% more likely than males; Black and Latinx JIA were 90% and 64% less likely than Whites, respectively; one unit increase in age was associated with a 6% decrease; those in households with incomes above $35,000 were 16–38% more likely; compared to JIA with no history of depression, those with occasional depression were 1.5 times more likely, those with consistent depression were twice as likely, and those who experience impairment due to depression were 2.5 times more likely; and, compared to JIA with positive recognition, those with school misconduct were twice as likely and those who graduated or dropped out of school were more than three times as likely to misuse opioids in the past 30 days. These results are illustrated in Figure 1 below.

Figure 1.

Adjusted Odds Ratios of Past 30-Day Opioid Misuse.

DISCUSSION

The current study found evidence that current and past runaways who enter the juvenile justice system have 2–3 times higher likelihood for opioid misuse compared to those who had no runaway history. These patterns are consistent with previous studies (Coady et al., 2007; Rhoades et al., 2014). Prior research on theory indicates that attachments to school, family, and peers discourage delinquency and substance use (Hirschi, 2002; Liu & Miller, 2020; Rigg & Ford, 2014). Efforts to address opioid misuse in justice settings may benefit from interventions that promote healthy relationships between peers and their parents or guardians.

The study also found that JIA with a history of depression, school misconduct, and those who graduated or dropped out of school had an increased likelihood of past 30-day OM. When adolescents drop out of school, they lose opportunities for prosocial connections (Kalu, Menon, & Quinn, 2020). These results suggest a need for improved dropout prevention services to establish social support. By maintaining school attachment through effective dropout prevention programs, the present role of school for adolescents creates an avenue of opportunity for school-based interventions to be implemented and an increased likelihood of positive school bonding. Similarly, an association with deviant peers and weak bonding with parents increases odds of running away (Chen, Thrane, & Adams, 2012; Hirschi, 2002); this association shows a need for more focus on positive social bonds as an intervention method for adolescents. JIA may benefit from an evidence-based cognitive-behavioral approach such as Multisystemic Therapy (MST). MST is designed to increase prosocial behavior and change youth’s ecology through family and community-based treatment. Research shows a high regard for MST as an effective model program through a reduction in recidivism rates (Sheidow & Henggeler, 2005).

Furthermore, these results highlight a high-risk population affected by the opioid epidemic and can inform actors of the juvenile justice system to make actionable insights within that system. For judicial officers, their efforts to address OM among JIA who have runaway could involve implementing formal diversion intervention programs, rather than processing adolescents through the system. By processing adolescents into detention and correctional facilities, JIA would have an increased risk of facing barriers for treatment, ultimately increasing the likelihood for opioid use disorder and other risky health behaviors (Mansion & Chassin, 2016). Through diversion intervention programs, JIA are provided wraparound services, including family counseling to reunite the runaway if circumstances permit, drug treatment, cognitive-behavioral therapy, and skill-building programs. To contribute to these efforts for effective diversion programs to be supported by judicial actors, future research could analyze the motivations of JIA who runaway and misuse opioids. By further understanding the etiology of those variables for JIA, evidence-based programs could be strengthened and supported by juvenile court judges.

Limitations

The study had limitations that provide context for interpreting the results. First, the generalizability to all JIA in the U.S. is limited because the FLDJJ sample is not a nationally representative sample. In addition, the sample represents Florida JIA with more risk or more severe offenses because low-risk offenders are not administered the full screen. Second, due to the cross-sectional data, the directionality between runaway experience and OM cannot be determined, and therefore, longitudinal data is required. Third, much of the information is self-reported data. The methodological limitation of self-report delinquency measures is well known (Huizinga & Elliott, 1986). Empirically verified inter-rater reliability and test-retest reliability could have strengthened the study. Diverse categories of opioids were collapsed under a single umbrella. Disintegrating these different types of opioids in future research to define unique use patterns can provide useful insights. These limitations are common in this vein of research and should be addressed in future research.

Despite these limitations, this study investigated a public health priority among an underserved health disparity population and made a new contribution to a scarce and esoteric body of research. It provided an unprecedented examination of runaway episodes and opioid misuse using comprehensive statewide data on the third largest juvenile justice population in the U.S. Congress enacted the Runaway Youth Act of 1974 (later renamed the Runaway and Homeless Youth Act) as Title III of the Juvenile Justice and Delinquency Prevention Act. It authorizes federal funding for community-based projects that provide temporary shelter, counseling, and aftercare services (OJJDP, 2019a). However, 9,000 to 11,000 children are turned away annually and unable to receive assistance (Fernandes-Alcantara, 2014). Fernandes-Alcantara (2014) critiques the Runaway and Homeless Youth Act to call for an increase in funding to programs for runaways as well as coordination between Continuum of Care homeless service providers and runaway population providers. Additionally, an establishment of quality training and technical assistance should be provided to runaway population providers to better serve vulnerable populations, such as JIA. Having quality resources for runaways that focus on the juvenile justice population would be beneficial and could lead to stronger attachment bonds to institutions, thus decreasing the likelihood of opioid misuse.

CONCLUSION

This study leveraged the attachment component of the social control theory to investigate the association between runaway status and opioid misuse among JIA. Current and past runaway episodes were more than twice as likely to have also misused opioids in the past 30 days, undercovering a potential pathway by which disparities in risk for opioid misuse among adolescents may occur. As a result, the Office of Juvenile Justice and Delinquency Prevention (OJJDP) is aiming to address this issue by initiating programs such as mentoring, drug treatments courts, reentry, partnerships, and research (OJJDP, 2019b). Developing evidence-based prevention and early intervention services that focus on runaway JIA and promote prosocial bonding may decrease misuse of opioids.